February 20, 2012

Book Excerpt from Beating the Reaper! Vol. 1: Trauma Medicine for the CCW Operator

Your pistol barks rapidly four times at the man who is firing wildly with an AK-47. You reach the relative safety of a concrete pillar and quickly reassess the scene. The gunman has stopped firing and is lying face down on the ground. You advance quickly, kicking the rifle away from his hands and note that your shots struck him in the throat and face. A quick 360 degree scan of the area reveals that several bystanders have been wounded and are lying in widening pools of their own blood.

Book Excerpt from Beating the Reaper! Vol. 1: Trauma Medicine for the CCW Operator (GunReports.com) —

Beating the Reaper!, Vol. 1: Trauma Medicine for the CCW Operator is directed toward the “Average Joe” who may have never taken a first-aid class, and certainly doesn’t consider himself to be a medically trained special operator.

Instead, he is someone who realizes that, just as with his shooting skills, he needs to have skill to help save someone’s life, perhaps his own, in the aftermath of shooting or other traumatic event. He’s the “CCW Operator” who doesn’t have a team medic nearby. He must show the same self-reliance that got him through the initial incident.

The authors of Reaper! wanted to replace the fear of doing the wrong thing in an injury situation with training, skills and confidence. They bring a wide range of experience to the project. Dr. John Meade has been a board-certified Emergency Physician for over 20 years. He is an EMS medical director, an instructor of Tactical Medics for SWAT teams, and a reserve police officer on a SWAT team, as well as Director of Tactical Medicine for Suarez International. “Sua Sponte” is the nom de guerre of an active duty military Special Operations medic who cannot yet reveal his true name for operational reasons. He has extensive experience treating our military members overseas in adverse circumstances and environments. Between the two of them, they bring together a combination of civilian, military, law enforcement, hospital, and out-of-hospital perspectives.

The excerpt below is from Reaper!’s Chapter 3, Hemorrhage Control:

Envision in your mind’s eye, that you are at the mall with your spouse. Just the two of you, out enjoying a Sunday afternoon, holding hands. You are browsing through shop windows, and watching the sheeple. Suddenly from your rear you hear a shriek, followed immediately by gunfire! You manage to draw your pistol, while pushing your wife to the ground. As you explode off of the X, your pistol barks rapidly four times at the man who is firing wildly with an AK-47. You reach the relative safety of a concrete pillar and quickly reassess the scene. The gunman has stopped firing and is lying face down on the ground. You advance quickly, kicking the rifle away from his hands and note that your shots struck him in the throat and face. A quick 360 degree scan of the area reveals that several bystanders have been wounded and are lying in widening pools of their own blood.

Unfortunately, you now see that among the wounded is your wife….. What Now?

The short fictional scene that we just described is one that most would consider to be a really bad day. The good news is that you smoked a bad guy. However, that is over shadowed by the fact that your wife is among the wounded and is bleeding severely. First things first! You need to stop the bleeding. So let’s jump right in and discuss how.

God’s perfect machine

Human bodies are machines. Complex machines, yes, but still machines. Just as with any other machine, before we can repair it, we need to have a basic understanding about its parts and how they operate.

Human Hydraulics

The human vascular system is very much like a hydraulic system. It has a pump (the heart), lines (the arteries, veins, and capillaries), and fluid (blood). Anyone who has a basic understanding of hydraulic systems knows that it requires pressure to function properly. To maintain pressure the system must remain closed, and contain sufficient amounts of fluid. Thus if one of the hydraulic lines is damaged and begins to leak, the pressure within the system drops, and the machine ceases to function. The same is true of our body’s vascular system. When we sustain a significant injury that causes us to bleed, we start to lose volume. Just as with a hydraulic system, the loss of volume causes a drop in pressure, leading to shock, and finally death.

Courtesy, Dr. John Meade

If someone has sustained an injury to a large or high-pressure vessel, then it is very likely that the volume and rate of blood loss will exceed the capability of the clotting mechanism. That is when rescuers must act aggressively to make the bleeding stop.

However unlike an airplane or bulldozer, our body immediately responds when we sustain damage to our hydraulic system with a variety of compensatory mechanisms. Part of the body’s response is to swell the tissues surrounding the injury, and to release natural blood clot forming materials (activated platelets and fibrin) out to the damaged area to help stop the bleeding. These materials bind together and form blood clots that act as a temporary patch of the blood vessel until the damage can either heal naturally or be repaired.

This natural response works very well when coping with damage to smaller or low-pressure blood vessels. However, if someone has sustained an injury to a large or high-pressure vessel, then it is very likely that the volume and rate of blood loss will exceed the capability of the clotting mechanism. That is when it is critical that we, as rescuers, act aggressively to make the bleeding stop.

Make it STOP!

There are several techniques that we routinely use to cause bleeding to stop. Generally, all of our hemorrhage control techniques function on the same basic principle of pressure causing occlusion of the bleeding vessel. The severity and the location of the bleeding will largely determine the most effective hemorrhage control technique.

Direct pressure

Applying direct pressure is still the gold standard technique for obtaining hemorrhage control in the non-tactical environment. Properly applied direct pressure is effective for controlling even severe hemorrhage. The key word is “properly”. The most common reason direct pressure fails to control hemorrhage is that it is improperly performed. For direct pressure to work, you must apply heavy pressure directly onto the damaged portion of the blood vessel for 10 – 15 minutes. It may take that long for the body’s natural hemorrhage control measures can catch up and form a blood clot.

When we say heavy direct pressure we mean really heavy direct pressure. You may actually have to put all of your weight into it. Understand that applying this type of pressure to the wound is going to be painful and very unpopular with the patient. Then again, dying is rather unpopular also.

This is probably a good time to reveal what we like to call the “3 P’s of tactical medicine”: Pain is the Patient’s Problem. We know it sounds cold hearted, but the reality is that many of the procedures necessary to save someone’s life are going to hurt. Naturally, we don’t purposely cause more pain than necessary, but the patient’s comfort level is of very little concern when we are trying to save their life. Do what you must do to save the patient’s life, than apologize for the discomfort later!

Courtesy, Dr. John Meade

To apply direct pressure: 1) Place gauze or other absorbent material over the wound. Although this can be done with just your hand, it tends to be easier to grab (less slippery) and more effective if you put something on the wound.

To apply direct pressure:

1) Place gauze or other absorbent material over the wound. Although this can be done with just your hand, it tends to be easier to grab (less slippery) and more effective if you put something on the wound.

2) Apply a firm and even pressure directly over the point of injury.

3) Hold pressure hard enough that you can tell the bleeding has stopped.

4) Hold pressure for 10-15 minutes and then check to ensure that the bleeding has stopped. Do not probe the wound, and do not remove the material that was used for applying pressure, as those actions may dislodge the blood clotting you have helped to create, and cause the bleeding to restart.

After the active bleeding has been arrested by applying direct pressure, the wound should be covered with a pressure dressing. A pressure dressing acts in much the same way that applying direct pressure does except that it does not require anyone to hold it. Furthermore, the dressing helps protect the wound.

Pressure dressings

There are many different “pressure dressings” on the market today and all of them work pretty much the same. Some are packaged better than others, and cost can range from reasonable to ridiculous. But the truth is that almost all of the available trauma dressings are some variation of a gauze pad sewn to an elastic wrap. Although purpose-made pressure dressings are convenient to pack and easy to use, there is nothing wrong with plain gauze and an Ace bandage.

The application of most pressure dressings is pretty straight forward. However in the interest of completeness, we will present pressure dressing application by the numbers. For the purposes of this demonstration we are utilizing an “Israeli” trauma dressing. However the application of other common pressure dressings is very similar.

1) Open the package and unroll the dressing enough to expose the absorbent pad.

2) Place the pad against the wound and begin rolling the elastic bandage around the wound.

3) Route the elastic bandage through the pressure device.

4) Pull the elastic bandage back over the top of the pressure device, forcing the bar down onto the pad, and continue tightly wrapping the wound with the elastic bandage ensuring that the edges of the pad are covered

5) Secure by hooking the end of the closing bar into the elastic bandage. REASSESS THAT THE BLEEDING HAS STOPPED!!

Packing a wound

If a wound is very deep, we need to first pack it with some kind of clean and absorbent material. One type of gauze commonly used for packing wounds is called “Kerlix”. Kerlix is 100% cotton gauze that is loosely woven to form a thin web-like sheet. It is this web-like construction that causes it to be such an effective wound packing material, because the loose cross woven threads hold small blood clots together, which then form into larger blood clots. The gauze acts very much like the rebar in a reinforced concrete wall.

For further information, click here